MRCPsych Training Programme Bedside Cognitive Assessment – a practical workshop Thursday 7th March, 2012 Dr Rupert Noad Department of Neuropsychology, Derriford Hospital, Plymouth rupert.noad@nhs.net Aims and objectives • Introduction to Neuropsychology • Understanding of the role cognitive assessment can play in clinical work • Understanding of different cognitive domains • Understanding of a clinical approach to assessing cognition • Experience of administering a bedside cognitive assessment battery What is Neuropsychology? • Neuropsychology is concerned with the relationship between brain and behaviour – i.e. how brain functions are organised • Attempts to understand how mechanisms within the brain influence thinking, learning and emotions • Neuropsychologists are particularly interested in how brain damage changes behaviour • This tells us about normal brain functioning e.g. WWI – lots of focal injuries Neuropsychologists….. • Aim to apply principles of brain-behaviour relationships to help patients understand their difficulties • Specialist neuropsychological assessments are used to test patients’ cognition and examine different brain functions • Neuropsychology knowledge is used as part of a psychological formulation of a patient’s difficulties The aim is to… • Have a good understanding of the way brain damage may impact on someone’s cognition • Have a good understanding of the way cognitive problems may affects someone's everyday functioning • What the psychological consequences of a disease may be and how they may manifest • What other explanations could be causing the cognitive symptoms being reported – in particular psychological difficulties Where might ‘brain variables’ inform your psychiatric/psychological formulation? Child - Why is this child under achieving at school? Adult – Differential diagnosis where neurological condition is suspected e.g. early onset psychosis versus epilepsy? Older adult - Differential diagnosis e.g. dementia versus depression? LD - What is this person’s level of understanding Other health, forensic, Neurorehab Typical questions • Does this person have cognitive difficulties and if so what is the severity? • Is this patient declining in ability? • Establishing the effects of treatment - surgery or radiotherapy • Are the person’s cognitive difficulties more related to psychological factors such as depression • To validate patients’ experiences • Capacity for consent, work, school, and independent living • Medically Unexplained symptoms? • Adjustment, depression, anger, anxiety related to a condition e.g. PD or Cavernoma Biopsychosocial approach Brain disorders are complex involving triad of: • Physical • Cognitive • Emotional But Many other secondary consequences e.g. family dynamics, loss that can underpin individuals’ difficulties Biological Psychological Social How do we understand Neuropsychological disorders? • Functional Neuroanatomy – what area of brain has been affected and what does it do? • Cognitive Neuropsychology – how can the patient’s symptoms be understood within cognitive models? • Clinical Neurology – what do we know about this disease – are the symptoms typical? • Psychiatry/Clinical Psychology – what do we know about the disease and its likely psychological consequences? What other factors, lifespan, systemic, childhood, financial etc. might be important? A practical way of thinking… • • • • • Presence versus absence Lateralisation Focal versus diffuse Acute/progressive versus chronic/static Aetiology/prognosis/implications Exercise: You have an orange, a newspaper and a pencil. How might you use these items to get an idea of someone’s cognitive abilities? What skills do you think you are able to test? Cognitive abilities • • • • • • • • • Orientation Intelligence Memory - amnesia Language – Aphasia, anomia Executive functions Apraxia Attention – hemispheric neglect Visuospatial ability – agnosia Other - alexia, agraphia, acalculia, anarithmetrica Making sense of cognition Following the video… • What cognitive difficulties is she experiencing? • How can you make sense of these? • Which area of her brain may be being affected? • What condition might cause this presentation? A clinical approach….. A framework for assessing cognition 5 steps: • The questions you ask the patient and carer • What you observe in the room • Informal tests of cognition • Bedside tests of cognition • Neuropsychological tests Domain e.g. memory Stage 1: Questions for patient/carer Stage 2: Observations in the room of amnesia? Stage 3: Informal tests of memory e.g. recent events, tea Stage 4: Bedside cognitive assessments e.g. address from ACE-R, MMSE Stage 5: Formal Neuropsychological assessment e.g. Camden, WMS The Bedside Cognitive Assessment Tool (BCAT) BCAT – Attention • Months of the year – Forwards – Backwards Attention • Critical to establish basic attention before any cognitive assessment • For example, critical for memory • Will be affected in disorders such as delirium, head injury, sub-cortical disorders BCAT – Orientation • Date, Month, Year, Day • City, Building, Floor/Level Orientation Need to establish orientation to Person, Place, Time and Situation What causes poor orientation? Causes of poor orientation • • • • • • • • Delirium Post traumatic amnesia Drug effects Amnesia – e.g.. Alzheimer's disease Frontal lobe impairment General confusion – e.g. unwell Institutionalisation Others….. Memory BCAT – Episodic Memory • Name and Address: – Linda Clark 59 Meadow Close Milford Surrey • Word List: – FACE, VELVET, CHURCH, DAISY, RED • Figure Copy • Faces BCAT - FACES BCAT – Facial recognition memory BCAT – Remote Memory • Dead or Alive: – ELVIS PRESLEY – TONY BLAIR – MARTIN LUTHER KING JR. – MADONNA BCAT – Semantic Memory • What do the following words mean? – UMBRELLA – STAPLER – BREAKFAST BCAT – Working Memory • Digit Span – Forwards – Backwards Memory • The most common reasons for referral. • Divided into several domains; • Episodic- personally experienced events. • Semantic- word meaning and general knowledge. • Working Memory- the limited capacity by which we retain information for a few seconds. Memory • Amnesia is a severe impairment in memory with intact perception and intellectual functions Memory impairments are causes by: Korsakoff's Syndrome • Alcoholic Blackout • Closed Head Injury • Electroconvulsive Therapy (ECT) • Transient Global Amnesia • Encephalitis • Dementia • Temporal Lobe Removals • Hysterical Amnesia In clinic – episodic memory In clinic • Recall of what had for main meal yesterday • Recall of what did for 17th birthday • What did you do on your last holiday? • Gradient from recent events to remote events Episodic Memory • Depends upon the hippocampal-diencephalic system. • Divided into anterograde and retrograde components. – Anterograde memory refers to the ability to recall newly encountered information. – Retrograde memory refers to the ability to recall past events. Semantic memory • Semantic memory is your total store of knowledge about yourself and the world • Often loss of autobiographical information can be an indicator of a non-organic cognitive disorder • However, there is semantic dementia as we have seen and retrograde memory loss e.g. post encephalitis can result in loss of semantic memory • Tests in clinic - General knowledge, Dead or Alive test • Bits from pyramids and palm trees Working Memory • This refers to the very limited capacity which allows us to retain information for a few seconds • Uses the dorsolateral prefrontal cortex. • Often appears as lapses in concentration and attention (going into a room and forgetting the purpose) Disorders of Working Memory • Lapses in working memory are common and increase with age, depression and anxiety. • Diseases which affect basal ganglia and white matter may present with predominantly working memory deficits. Language BCAT – Expressive Aphasia • Naming: – “What is this?” BCAT – Repetition • Repeat after me: – PROSPER – GARDEN – PORCUPINE – ECCENTRICITY • “Above, beyond and below” • “Today is a sunny and windy day” BCAT – Receptive Aphasia • Single Word Comprehension: – Point to: • • • • • The source of illumination Object used to tell the time Object to sit on Surface that you walk on Entrance to the room BCAT – Auditory Comprehension • Answer YES or NO: – – – – – Is a hammer good for cutting wood? Does a stone sink in water? Do dogs fly? Do you put on your socks after your shoes? Do you peal a banana before eating it? • Syntax – – – – With the pencil touch the pen Touch the pencil with the pen With the pen touch the pencil Touch the pen with the pencil Language Divided into different processes; • Expressive language - production • Receptive language - comprehension • Plus reading and writing Disease affecting language • • • • Stroke Frontal temporal dementia Corticobasal degeneration Head Injury Need to differentiate dysarthria from dysphasia Expressive aphasia in clinic In Clinic • Is the patient as fluent and articulate as normal? Has there been a deterioration in grammar? • Is there a misuse of words (paraphasias -)? (semantic - clock for watch) or phonemic - baby flitter for baby sitter) Bedside tests • Word repetition: Use a series of words of increasing complexity e.g hippopotamus, emerald, perimeter. Listen for phonemic paraphasias. • Sentence repetition: use well known phrase “no ifs, ands or buts” Receptive aphasia In clinic • Does the patient have difficulty following complex instructions? • Does he/she struggle to keep track of group conversations? • Does he/she find using the telephone particularly difficult? Bedside tests • Use several common items (coin, pen, key) and ask patient to point to one to assess single word comprehension. • Test sentence comprehension and syntax commands with common items and commands e.g. “touch the pen” or “if the lion ate the tiger, who remained?” Apraxia BCAT – Apraxia • Melokinetic – “Touch each finger tip of your right hand with the thumb of your right hand.” • Buccolingual – “Lick your lips” – “Blow up your cheeks” • Ideomotor – Observe any clumsy action with pen use – Interlocking Finger Test • Ideational – “Fold this piece of paper in half, write your name on it and place it inside this book.” Apraxia Inability to perform a movement with a body part despite intact sensory and motor function - due to deficits in higher cortical control of movement Can be: • Ideomotor – inability to draw or construct simple configurations • Ideational - inability to create a plan for or idea of a specific movement, for example, "pick up this pen and write down your name” Ideomotor apraxia In clinic Does patient have difficulty with tasks such as using a knife and fork? Does patient have difficulty with dressing? Bedside tests • Imitation of gestures, and gestures to command (e.g. wave, salute) • Use of imaginal objects (comb your hair, brush your teeth). Common error is to use body part as a tool (e.g. finger for toothbrush) • Oral apraxia (blow out a candle, stick out your tongue) Figure 1: Hand movements in apraxia. Reproduced from: Goldberg G. Imitation and matching of hand and finger postures. Neuroimage 2001;14:S132-6, with permission from Elsevier. Kipps, C M et al. J Neurol Neurosurg Psychiatry 2005;76:i22-30i Copyright ©2005 BMJ Publishing Group Ltd. Agnosia • Patient cannot recognise the meaning of visually presented objects • Recognition sometimes better for real rather than imagined or lined drawings • It is particularly associated with lesions of the left occipital lobe and temporal lobes BCAT – Prosopagnosia • Can you tell me who these people are? Prosopagnosia • A specific deficit in recognising familiar faces, sometimes even including own • Patients can often appreciate the aspects of faces, such as age, gender or emotional expression. Visual inattention/Neglect Neglect of extrapersonal space Patients with focal right hemisphere lesions often fail to respond to stimuli in the opposite half of extrapersonal space. May manifest as a failure to talk to visitors on the left side of the bed, a tendency to ignore food on the left half of the plate, constantly bumping into objects on the neglected side Bodily neglect/Anosognosia In its most profound form, patients deny the presence of hemiplegia despite evidence to the contrary. BCAT – Neglect • Clock Drawing • Image Copy Figure 2 Impaired clock face drawings in dementia. Kipps, C M et al. J Neurol Neurosurg Psychiatry 2005;76:i22-30i Copyright ©2005 BMJ Publishing Group Ltd. Frontal Lobes/Executive BCAT – Executive Functioning • Fluency – ANIMALS & ‘B’ • Proverbs – A stitch in time saves nine – People in glass houses shouldn’t throw stones • Conflicting instructions – Tap twice when I tap once – Tap once when I tap twice • Go-No-Go tasks – Tap once when I tap once – DON’T Tap when I tap twice BCAT – Executive Functioning (cont.) • Multiple Loops • Alternating Sequence • M’s and N’s BCAT – Executive Functioning (cont.) • Hayling Test – Complete these sentences with the appropriate word: • I put my shoes on and I tie my ……… • It was raining cats and ……… – Complete these sentences with an inappropriate word: • John bought candy at the ……… • An eye for and eye, a tooth for a ……… • I washed my clothes with water and ……… Frontal Lobe functioning • Generally thought to be a (dorsolateral) frontal lobe function, although this set of skills is probably more widely distributed in the brain. • Impairments relate to planning, judgement, problem solving, impulse control and abstract reasoning. Disorders of Executive and frontal lobe function. • Brain injury • Alzheimer’s disease, even in early stages. • The majority of the frontal lobe is subcortical white matter and the leucodystrophies, demyelination and vascular pathology all cause executive dysfunction. • Basal ganglia disorders also impair executive skills e.g. progressive supranuclear palsy (PSP). Exploring executive dysfunction in the clinical interview. • There are a broad range of skills encompassed by “executive function” so it is worth testing in a number of different ways. • Has there been a drop off in performance at work or in household tasks and hobbies? (reflecting impairment in sequencing and planning) • Have any perseverative behaviours been noticed? • Are there any reports of poor judgement or an inability to modify behaviour according to changing situations. • Appreciation of jokes and puns also depends on complex abstracting ability and so is frequently affected. Don’t forget the psychiatric perspective! Cognitive symptoms associated with mental health disorders: • Anxiety • Low mood/depression • PTSD • Psychosis Summary • Cognitive assessment can be very helpful • It can give you new types of data over and above a clinical interview • However, the data is ‘soft’ and is dependent upon the interpretation of the clinician • Neuropsychological assessment should be FORMULATION driven not DATA driven The science/art To be able to use cognitive data to help in the conceptualisation/diagnosis of a patients clinical problem Biological Psychological Social Can you remember?... • The name and address • The list of words • The three figures you copied Great Resources • Cognitive assessment for Clinicians – 2nd Ed (2007). John Hodges (in fact anything by John Hodges) • Neuropsychological Neurology: The Neurocognitive Impairments of Neurological Disorders – Andrew J Larner • Cognitive assessment for Clinicians (2001). Kipps and Hodges (JNNP) Supplement • Concise Guide to Neuropsychiatry and Behavioral Neurology (second Ed) - Cummings and Trimble. Thank You Any questions?